The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COVENANT MEDICAL CENTER 3421 WEST NINTH STREET WATERLOO, IA 50702 Feb. 25, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of policies, hospital documents, video footage, medical record, and interviews with staff, the administrative staff failed to ensure Security Officers and nursing staff monitored and evaluated patients to minimize the risks and opportunities for elopements by court committed patients in the ED (Emergency Department).

A court committed patient eloped on 2/23/16 from the ED while being evaluated for methamphetamine abuse and paranoid delusions. The Security Officers and nursing staff failed to ensure the patient remained safe and secure in the ED. The ED staff notified the police after the patient had eloped. On 2/23/16, the police returned the patient to the ED.

1. The Security Officers and nursing staff failed to provide patient care for court committed patients that required specific monitoring, patient cares, and visual contact. (Refer to A 144)

2. The nursing staff failed to assess and monitor a anxious, paranoid, delusional, agitated patient, who continued to pace in his room, and refused medications. (Refer to A 395)


(Refer to A-144)

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure the protection of all court committed patients and ED patients. This resulted in the patient elopement from the ED.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of documents, policies, procedures, medical record, video footage, and interviews with staff, the administrative staff failed to ensure the ED (Emergency Department) staff followed policies and procedures to provide a safe environment for patients with psychiatric conditions.

The ED staff were aware the patient was court committed to the hospital for a psychiatric evaluation. The ED staff and security failed to protect Patient #1 safety by allowing him to walk out the ED wearing only paper scrubs, take possession of an ambulance, drive out of the ambulance garage and damaged the door. The patient drove the ambulance approximately 6 blocks away from the hospital and abandoned it. After staff notified police, the patient was found and returned to the ED.

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities" dated 1/14, included in part, "...as a patient...you have the right...to...receive care, consistent with sound medical and nursing practice, in a ....safe and secure environment...be assured of reasonable safety within the hospital..."

Review of the hospital policy titled, "Elopement Procedure, Inpatient" dated 2/16, included in part, "...All court committed patients...deemed an elopement risk, staff will visually confirm and monitor patient's whereabouts every 15 minutes...nursing interventions aimed at avoiding elopement are too followed and documented as follows: assess the patient's level of anxiety, fear, and frustration...recognize patient refusal of medication and non-compliant behavior may indicate the patient is at a high risk for elopement...prevention measures are to be followed and documented as follows:..."triggers" such as clothing...should be stored out of sight of the patient...court committed patients will remain under direct observation..."

Review of the hospital policy titled, "Care of Patients Presenting with Psychiatric Complaints in the Emergency Department" with a revision date of 5/15, included in part, "...the nurse caring for the patient will assess for the presence of the following symptoms...Delusions or paranoid thoughts...Threatening or aggressive behavior...Committal...If the patient is positive for any of the above symptoms, they will be placed in a behavioral health room...changed into paper scrubs, their clothing and belongings will be removed...searched and secured...they will be placed in direct observation...Direct observation of the patient will be performed by Security personnel. If Security leaves...to respond to an urgent situation, the ED Charge Nurse will assign an ED associate to perform the Direct Observation of the patient until the Security personnel returns...Direct Observation will keep the patient within his or her view at all times...Any patient who displays any of the above behaviors...will not be allowed to leave the Department...if the patient attempts to leave...a Code Strong will be called and the patient detained within the Department for his/her own satiety...For all patients who are positive for any of the above symptoms...The ED provider will call the on-call Hospital psychiatrist for a consult...If the behavioral health specialty nurse comes to the ED, the nurse will report his or her findings to the on-call psychiatrist...the on-call psychiatrist will communicate the decision to the ED provider...On initial assessment, the psychiatric nurse will verify medications and initiate a focused psychiatric care plan to support care from the ED staff...Elopement precautions will be in place for all patients who display any of the above behaviors...Staff will use caution when entering or leaving the patient exam room...be aware of anxious patients who may be in the area of the door...draw the patient away from the door...Assess patient's level of anxiety, fear and frustration...Recognize patient refusal of medication and non-complaint behavior may indicate the patient is a high risk for elopement..."

2. Review of hospital document titled "Competency Tasks" Security no date, included in part, "...Officers will work with the Emergency department...if the patient is an elopement risk then an officer will be at the door of the patient's room...if the patient is aggressive and is with staff...the officer should remain directly outside the room...if the patient attempts to elope, a security assist required will be called immediately and officers will do anything possible to prevent the patient from eloping..."

Review of a hospital document titled, "URGENT MESSAGE" dated February 29, 2016, completed by the Vice President of Care Services/Chief Nursing Officer included in part, "...Recent events that have happened within our organization...there needs to be a heightened focus on the importance of...preventing elopements from taking place within our organization...Attached. You will find key points that everyone in our organization needs to understand regarding patients at risk for elopement...Definition...A patient who is not able to protect themselves from harm or death...Psychosis, self-destructive behaviors...Impaired...A patient who is not able to make good decisions because of an underlying medical problem...drugs...For patients who are deemed to be an elopement risk upon arrival to the ED...all visual observations shall be documented in the patient's medical record. If a patient is a court committed....monitoring will be continuous...Assess the patient's level of anxiety, fear and frustration...Recognize patient refusal of medication and non-compliant behavior may indicate the patient is a high risk for elopement...spending targeted one on one time can prevent an elopement...Continuous monitoring will remain in place as long as the patient...are a high risk for elopement..."

Review of a hospital document titled, "Incident 16-89" no date completed by Staff H, Security Officer included in part, "At 7:16 AM, [Security Officer Q and Security Officer H] were watching patients in ED rooms 17, 22, 23. At this point security officers were dealing with 2 patients that were elopement risks...in the ED. I checked down at [Patient #1] and safety companion. [RN I] was in the door way talking to [Patient #1]. At this time I turn back around and started to write down information on ED patient 23 being escorted to the restroom and log that safety companion was in doorway of room. As I completed the logs of both patients of the activities that occurred, I heard the emergency egress door alarm go off and notified [Security Officer Q] so he could turn the alarm off as I couldn't due to watching the 3 patients in the ED at the time...Safety companion [RN I] then alerted security that [Patient #1] was just gone. At this time, I went to the emergency egress door and then out to talk with the construction crew to see if they saw a male, medium height, and wearing blue scrubs run by...I then headed back to the ED to recheck the room due to past incidences where rooms were not properly cleared and secured. I radioed [Staff Q] of his location. He was returning ED patient to room 23...I then walked...to get the security van to do a drive around the hospital campus...it appears [Patient #1] backed an ambulance through southwest door of the ambulance bay..."

3. The surveyor, along with the Security Manager viewed the video footage recorded on the hospital security cameras on the morning Patient #1 eloped. The Security Manager reported at 7:18 AM, Patient #1 exited his ED room, walked approximately 40 feet through the nurse's station. The video footage showed Patient #1, wearing blue paper scrubs and carrying a bag with his personal belongs exited the nurse's station at the same time Staff J, Interpreter entered the nurses station. The patient turned left, walked approximately 32 feet, stopped, and attempted to open an alarmed, locked door. The patient then turned left and traveled approximately 172 feet through an outer corridor of the ED. At the end of the ED corridor, the patient turned right and walked 42 feet to the ambulance bay entrance doors. Patient #1 continued to walk approximately 100 feet to where Patient #1 entered an unlocked, unoccupied ambulance that had keys in the ignition. At that time, Patient #1 placed the ambulance in reverse and backed the ambulance through closed ambulance bay doors and drove away. The patient traveled a total of 336 feet throughout the ED prior to eloping.

4. Review of Patient #1's medical record, hospital document and staff interviews revealed on 2/22/16 the court committed patient was admitted to the ED for a psychiatric evaluation. The Security Officers and nursing staff documentation revealed on 2/23/16 from 1:30 AM to 7:15 AM, the patient was anxious, paranoid, hallucinating, refused medications, and was pacing in his room. The Behavioral Health RN and ED staff failed to implement interventions to address the patient's escalating behaviors, and need for increased monitoring. The Behavioral Health RN and ED nursing staff reported they provided verbal reports of the patient's behavior to [ED Physician QQ]; however, the medical record lacked specific information that may have been reported to ED Physician QQ or on-call Psychiatrist OO and lacked documentation showing ED Physician QQ, who was responsible for the patient's care and treatment had any interaction with the patient from 9:40 PM on 2/22/16, to 7:28 AM on 2/23/16.

A Clinical History of Present Illness summary on 2/22/16 at 7:32 PM, completed by ED Physician MM, documented the patient presented to the ED for a court committal for a psychiatric evaluation. The court committal documents stated the patient was acting very unusual, used methamphetamines, and showed signs of paranoia and delusion. The patient believed his daughter was possessed, his parents were trying to kill him, and his entire family is the devil.

A Physical Exam note, at 7:57 PM, completed by ED Physician MM, documented the patient was agitated, argumentative, and anxious.

A hospital document titled, "Security at Risk Patient Monitoring Log, completed by Staff AA, Security Officer, documented Patient #1's activity included:

From 8:30 PM on 2/22/16 to 1:00 AM on 2/23/16 - patient in bed sleeping.
At 1:30 AM, Patient pacing.
At 1:33 AM, Patient pacing, RN in at 1:35 AM.
At 2:00 AM, Patient still pacing.
At 3:00 AM, Patient pacing again.
At 4:00 AM, Patient pacing.
At 4:30 AM, Patient still pacing.
At 4:55 AM, RN in room.
At 5:00 AM, Patient pacing.
At 5:04 AM, RN in with patient at 5:20 AM
At 5:50 AM, Patient at door.
At 6:00 AM, [Staff Q, Security Officer] taking watch.
From 6:00 AM to 7:15 AM, the log lacked documentation of the patient's activity and/or any information related to nursing staff entering or exiting the patient's room.

A mental health progress note, at 5:30 AM, completed by Behavioral Health RN G, documented Patient #1 was anxious, paranoid, suspicious, and was unable to follow directions to stay behind the carpet line of his room. RN G documented the patient reported he was upset, uneasy, not sleeping, was afraid the oxygen in the walls would explode, felt unsafe in his room, and was afraid the staff may harm him. RN G documented she discussed nicotine withdrawal and medication with Patient #1 however, the patient refused medication and she told the patient to notify the nurse if the patient needed nicotine gum or anxiety medication. The note lacked documentation of any information related to Patient #1's escalating behaviors, refusal of medications, hallucinations, failure to remain inside the ED room, that may have been reported to Staff M, ED RN, on-call Psychiatrist OO, and/or ED Physician MM.

A nursing note, at 6:09 AM, completed by Staff M, ED RN, documented Patient #1 was standing at the door talking with a security officer. The note lacked specific observations of the patient's behaviors or any information related to the patient's needs.

A nursing note, on 2/23/16 at 7:00 AM, completed by Staff M, ED RN documented care transferred from Staff M, ED RN to Staff K, ED RN. The note lacked documentation of change-of-shift reporting and patient information. The note lacked documentation of an evaluation and assessment of patient's behaviors or any information related to the patient's needs.

A nursing note, on 2/23/16 at 7:09 AM, completed by Staff M, ED RN documented Patient #1 was standing in the doorway of his room and the patient had no needs. The note lacked specific observations of the patient's behavior, increase monitoring, or any information that may have been reported to Staff K, ED RN.

A physician progress note, on 2/23/16 at 6:36 AM, completed by ED Physician QQ, documented Patient #1 was calm, experienced a good night, woke up around 4:45 AM and was hungry. ED Physician QQ, documented care transferred to ED Physician NN. The note lacked specific information of the patient's esculating behaviors that may have been reported to ED Physician QQ.

5. During an interview on 2/24/16 at 6:45 AM, Staff D, EMT reported on 2/23/16 at 7:00 AM they had just returned from a call and after pulling ambulance #5 into the garage she went the ED with paperwork. EMT D reported she left the keys in the ambulance and did not lock the doors. EMT D stated, "I was standing approximately 40 feet from the ambulance when I saw a male dressed in blue paper scrubs carrying a personnel belongings bag running towards the ambulance. The patient threw the bag over to the passenger seat and got in the driver's side." EMT D stated, " I yelled, "Hey you can't be in here and need to get out!" EMT D stated, "Within seconds of getting in the ambulance, he started the ambulance, put it in reverse and backed out through the doors to the garage and down the drive way." EMT D stated, "After the incident I ran into the ED and told the security and nursing staff a male patient had eloped after stealing an ambulance."

During an interview on 2/24/16 at 10:05 AM, Staff I, Behavioral Health RN reported on the morning of 2/23/16 she was assigned to work in the ED to monitor Patient #1. Staff I stated, "When I arrived to the ED [Staff G, Behavioral Health RN] reported the patient was paranoid and was standing at the door of the room a lot." Staff I stated, "I thought the patient was on elopement precautions." Staff I stated, "When I got to the room at 7:15 AM, I saw his bed was close to the door. He was restless, a little agitated, and he looked off and on at me. [Patient #1] was standing at the door next to the nursing corridor and I was in the room. For a psych nurse we don't want the bed next to the door. I went up to the head of the bed. I was 6 to 7 feet away from the patient. I looked up and the patient was gone." Staff I stated, "I walked out of the room and there was no staff in the inner corridor (nurse's station) by his room but they were at the other end of the inner corridor." Staff I stated, "[Patient #1] went right out his room to the exit doors." Staff I stated, "I went that way and went through the exit door and could not see him." Staff I reported she told the Security Officer the patient left the ED. Staff I stated, "I wish I would have went with security to see [Patient #1] until I knew his cares better."

During an interview on 2/24/16 at 11:20 AM, ED Physician MM reported after reviewing court committal paperwork, he completed a psychiatric and physical medical screening examination (MSE) to determine if the patient was appropriate for admission to the 1 available bed on the behavioral health unit. ED Physician MM stated, "If we have a bed we would contact the access nurse and a psychiatrist and talk about the admission, if we don't, the patient has to be held until placement is found." ED Physician MM stated, "My diagnosis after evaluation was methamphetamine induced psychosis. The patient was agitated, delusional, paranoid, very defensive and angry." After the patient refused to change into paper scrubs and allow blood draws for lab work, Ed Physician MM ordered an injection of Geodon (an antipsychotic medication used to treat mental/mood disorders, by decreasing hallucinations, confusion and agitation). ED Physician MM reported the (Geodon) medication helped to calm the patient; and after 45 minutes the patient changed into the paper scrubs and allowed the lab work. ED Physician MM reported when he left that evening at 9:40 PM, the patient was sleeping in an ED observation room.

During an interview on 2/26/16 at 11:00 AM, Staff M, ED RN stated, "I took Patient #1 from [Staff S, ED RN] between 11:30 PM and midnight. I was there when he first came in." ED RN M stated, "The first part of the night [Patient #1] was resting peacefully. When the patient woke up he was pacing around the room so I went in and talked with him. He said he wanted to go home. I asked him if he wanted anything to calm his nerves. He said no." When asked what the patient's demeanor was, ED RN M stated, "He was looking out the door every time I interacted with him. He seemed a little down and wanted to go home." When asked if the ED physician was aware of Patient #1's behaviors, ED RN M stated, "[ED Physician QQ] was aware the patient was pacing most of the night but it was a verbal exchange of information and most likely it would not be documented in the medical record."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of policies, procedure, hospital documents, medical record, and interviews with staff, the hospital failed to ensure to schedule an adequate number of licensed nursing staff to provide safe patient care, to assess and monitor court committed patients in the ED (Emergency Department), to minimize the risks and opportunities for elopements by patients.

1. Failure to schedule an adequate number of licensed registered nurses and licensed practical nurses to provide specific monitoring, patient cares, and direct visual contact for court committed behavioral health patients, allowed a delusional, anxious, agitated, paranoid patient, who refused medications and paced in the patient's ED room to elope from the ED. The patient ran from his ED room, through the ambulance garage, took possession of a ambulance, drove through the ambulance doors, and then drove the ambulance approximately 6 blocks away from the hospital and abandoned it. Failure to ensure the ED had an adequate number of licensed staff to provide safe patient care placed all behavioral health patients in the ED at risk for elopement and harm. (Refer to A 392 and A 395)

2. Failure to ensure nursing staff monitored and assessed a patient with signs and symptoms of escalating behaviors placed the patient at risk for adverse outcomes. (Refer to A 395)

(Refer to A 392 and A 395)

The cumulative effect of these systemic failures and deficient practices resulted in the hospitals inability to provide adequate numbers of nursing staff with knowledge to provide safe patient care.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of policies, procedures, documents, medical record, and interviews with staff, the administrative staff failed to schedule an adequate number qualified licensed registered nurses and licensed practical nurses to provide patient care as needed for 1 court committed behavioral health patient in the ED (Emergency Department.)

Hospitals are required to ensure that qualified staff is available to ensure patient's needs are met and to reduce the risk of patient harm. Failure to ensure the hospital administrative staff scheduled an adequate number of qualified licensed registered nurses and licensed practical nurses to provide safe nursing care for all patients resulted in 1 court committed behavioral health patient in the ED eloped. (Patient #1)

Findings include:

1. Review of a hospital policy titled, "Patient Care Overview" with a revision date of 11/14, included in part, "...Staffing Plan is designed to provide for the delivery of quality patient care...developed in accordance with our regulatory standards, practice standards and standards of care... adjustments are made based on...patient acuity, work load, and the number of qualified department personnel scheduled for the...shift...Nursing Care...provided to patients in the...Emergency Department...An adequate number of licensed registered nurses available for care of the patient...patient assignments based on...Patient status...acuity complexity...Circumstance/Setting...Safety... appropriate...training...Staff competency... Frequency/Complexity of required monitoring... Standards of Practice...assess the competency of the individual nurse...The nurse shall be competent and current in their area of nursing practice...The nurse shall ensure the delivery of safe nursing care to the patient..."

Review of a hospital procedure titled, "Elopement Procedure" with a revision date of 5/15, included in part, "...In case of a un-witnessed elopement...Notify RN in Charge Immediately and alert all staff to conduct a room to room search..."

2. Review of the hospital document titled, "Job Description RN" with a revision date of 1/2015, included in part, "...The RN supervises and coordinates care provided to patients by...other nursing team members...Assigns and coordinates patient care incorporating patient acuity and the skills, knowledge and abilities of the team members...Maintains ongoing communication with interdisplinary team members throughout the shift, at shift change, and transfer of care...Documents completely and comprehensively...in accordance with policy..."

3. A nursing note on 2/23/16 at 7:20 AM, completed by Staff I, Behavioral Health Unit RN included in part, "I walked into room 17. I tried to get him to sit and lay down on the bed. I tried to move the bed in the room it was close to the door. Patient immediately left the room and ran. I tried to run out and find the patient. The patient continued to run. The patient ran out the back door of the ED. I then called out for security to assist." The note lacked documentation of an immediate notification to the Charge ED RN and Security Officers at the time when the patient eloped from his ED room in accordance with the hospital procedure.

4. During an interview on 2/24/16 at 10:05 AM, Staff I, Behavioral Health RN reported on the morning of 2/23/16 she was assigned to work in the ED to monitor Patient #1. Staff I stated, "When I arrived to the ED [Staff G, Behavioral Health RN] reported the patient was paranoid and was standing at the door of the room a lot." Staff I stated, "I thought the patient was on elopement precautions." Staff I stated, "When I got to the room at 7:15 AM, I saw his bed was close to the door. He was restless, a little agitated, and he looked off and on at me. [Patient #1] was standing at the door next to the nursing corridor and I was in the room. For a psych nurse we don't want the bed next to the door. I went up to the head of the bed. I was 6 to 7 feet away from the patient. I looked up and the patient was gone." Staff I stated, "I walked out of the room and there was no staff in the inner corridor (nurse's station) by his room but they were at the other end of the inner corridor." Staff I stated, "[Patient #1] went right out his room to the exit doors." Staff I stated, "I went that way and went through the exit door and could not see him." Staff I reported she told the Security Officer the patient left the ED. Staff I stated, "I wish I would have went with security to see [Patient #1] until I knew his cares better."

During an interview on 2/24/16 at 12:50 PM, Staff L, ED Manager stated, "It was busy, there were 3 psych patients in the ED including [Patient #1]." The ED Manager stated, "The safety companion [Staff G, Behavioral Health RN] did not verbally notify anybody." The ED Manager stated, "We never had safety companions. It has just been since the flood on the unit." The ED Manager reported on 2/15/16 after the flood on the Behavioral Health unit, the Behavioral Health RN's (safety companions) started to work in the ED. The ED Manager reported the Behavioral Health RN's did not receive orientation to the ED process and the ED Behavioral Health process. The ED Manager stated, "It is more of an urgency responding to patients who attempt to elope because our unit is not locked."

During an interview on 2/25/16 at 10:20 AM, Staff F, Director of the Behavioral Health Unit stated, "Behavioral Health RN's did not receive orientation on how to work in the ED. Behavioral Health nurses did not go down to the ED that often until after the flood. We gave them the option of going down to the ED to assist with monitoring psych patients instead of being off with no pay or taking vacation while the Behavioral Health Unit was being repaired."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of policies, documents, medical records, and staff interviews, the administrative staff failed to ensure nursing staff evaluated the care for court committed patient to assure patients received the care and treatment to meet the patients care needs in the ED (Emergency Department).

Failure to ensure nursing staff evaluated a court committed patient's care to assure patients received the care and treatment needed to ensure the patient would remain safe and secure in the ED resulted in 1 court committed patient (Patient #1) eloped from the ED. The patient left the ED, took possession of an ambulance, drove through the ambulance doors, and then drove the ambulance approximately 6 blocks away from the hospital and abandoned it.

Findings include:

1. Review of hospital policy, "Assessment of Patient" dated 2/16, included in part, "...focused assessment...actual and potential problems of the patient...Assessment involves systematic collection of data and occurs continuously as to maintain awareness of patient's needs and effectiveness of interventions...Assessment and reassessment...throughout the entire patient stay...All assessments and reassessments will be documented...Acute change of condition...may occur...abruptly or over several hours...presenting as changes in...mood, cognition, behavior...An acute change of condition, without intervention, may result in complications or death..."

Review of the hospital policy titled, "Unit Structure and Practice Model", dated 1/14, included in part, "...Description: The Emergency Department is a 24 bed unit...treatment rooms consist of...four exam rooms may be used for Behavioral Health patients...any individual seeking emergent...care will be properly assessed..."

2. Review of the hospital document titled, "Job Description RN" with a revision date of 1/2015, included in part, "...The RN utilizes critical thinking to assess, plan, implement and evaluate outcome based care of patients...The RN facilitates communication with physicians, patient...other departments and/or team members...Principal Accountabilities and Essential Functions of the Job...Conducts an initial assessment...Identifies patient problems...Prioritizes patient care needs/activities...Focuses ongoing reassessments on actual or potential problems/needs of the patient...Communicates relevant clinical information to the physicians regarding the patient's condition...Maintains ongoing communication with team members throughout the shift, at shift change, and transfer of care...Documents completely and comprehensively...in accordance with policy..."

3. Review of Patient #1's medical record revealed the patient was delusional, anxious, paranoid, hallucinating, refused medication, did not sleep, and continued to pace in his ED room.

Behavioral Health Screening note, on 2/22/16 at 7:15 PM, completed by Staff S, ED RN documented the patient was delusional, paranoid, and was an imminent danger to self, others, and property. Staff S documented the staff provided direct observation of the patient in the ED behavioral health room.

A triage nursing note, on 2/22/16 at 7:34 PM, completed by Staff S, ED RN lacked information regarding the patient's condition upon arrival to the ED, nursing observations of the patient's behavior or symptoms demonstrated by the patient.

A mental health progress note, on 2/22/16 at 7:55 PM, completed by Staff G, Behavioral Health RN, documented the patient was depressed and tearful.

A mental health and addiction psychosocial assessment note, on 2/22/16 at 8:50 PM, completed by Staff G, Behavioral Heath RN, documented patient was anxious, restless, and compulsive after patient received IM Geodon for agitation. Staff G documented the patient's treatment for psych and drug dependency was in progress as soon as the patient was evaluated by the healthcare team and physician. The note lacked documentation to show the results of the mental health and addiction psychosocial assessment was reported to on-call Psychiatrist OO in accordance with hospital policy or if the results may have been reported to ED Physician MM, and ED nursing staff.

A nursing note, on 2/23/16 at 1:28 AM, completed by Staff M, ED RN, documented Patient #1 requested to call family and was pacing in his room.

A nursing note, on 2/23/16 at 3:07 AM, completed by Staff AA, ED Technician, documented Patient #1 was walking around in his room. The note lacked documentation if the patient's behavior may have been reported to Staff M, ED RN.

A nursing note, on 2/23/16 at 3:21 AM, completed by Staff M, ED RN, documented Patient #1 was pacing around in room, the patient denied any needs, and no distress was noted.

A nursing note, on 2/23/16 at 4:00 AM, completed by Staff M, ED RN, documented Patient #1 was pacing in his room, denied something for his nerves, and no distress was noted.

A nursing note, on 2/23/16 at 4:27 AM, completed by Staff M, ED RN, documented Patient #1 was pacing in his room and no distress was noted.

A nursing note, on 2/23/16 at 5:05 AM and at 5:31 AM, completed by Staff M, ED RN, documented 5 East nurse [Behavioral Health, RN G] was in the patient's room. The note lacked specific observations of the patient's behavior or any information related to Patient 1's behaviors that may have been reported to Behavioral Health RN G.

A mental health progress note, on 2/23/16 at 5:30 AM, completed by Behavioral Health RN G, documented Patient #1 was anxious, paranoid, suspicious, and was unable to follow directions to stay behind the carpet line of his room. RN G documented the patient reported he was upset, uneasy, not sleeping, was afraid the oxygen in the walls would explode, felt unsafe in his room, and was afraid the staff may harm him. RN G documented she discussed nicotine withdrawal and medication with Patient #1 however, the patient refused medication and she told the patient to notify the nurse if the patient needed nicotine gum or anxiety medication. The note lacked documentation of any information related to Patient #1's escalating behaviors, refusal of medications, hallucinations, failure to remain inside the ED room, that may have been reported to Staff M, ED RN, on-call Psychiatrist OO, and/or ED Physician MM.

A nursing note, on 2/23/16 at 6:09 AM, completed by Staff M, ED RN, documented Patient #1 was standing at the door talking with a security officer. The note lacked specific observations of the patient's behaviors or any information related to the patient's needs.

A nursing note, on 2/23/16, documented care transferred from Staff M ED RN to Staff K, ED RN at 7:00 AM. The note lacked documentation of change-of-shift reporting and patient information.

A nursing note, on 2/23/16 at 7:09 AM, completed by Staff M, ED RN documented Patient #1 was standing in the doorway of his room and the patient had no needs. The note lacked specific observations of the patient's behavior or any information related to the patient's needs.

4. During an interview on 2/24/16 at 8:55 AM, Staff G, Behavioral Health RN reported on 2/22/16 at 7:50 PM, she completed a mental health and addiction psychosocial assessment. Staff G stated, "The patient was very energetic, paranoid, and he didn't want to stay in the ED because he thought there were tanks in the wall that might explode." Staff G stated, "I took the assessment paper work to [Staff S, ED RN] and explained the patient was paranoid and worried about not being taken care of by the ED nursing staff."

During an interview on 2/24/16 at 11:50 AM, Staff K, ED RN stated, "I was the nurse on duty when the incident occurred with [Patient #1]. During the night he was paranoid." When asked if the ED RN K assessed Patient #1, ED RN K stated, "I was at the other end of the ED. I did not have a chance to evaluate him."

During an interview on 2/26/16 at 11:00 AM, Staff M, ED RN stated, "I took Patient #1 from [Staff S, ED RN] between 11:30 PM and midnight. She reported he was having hallucinations." ED RN M stated, "The first part of the night he was resting peacefully. When the patient woke up he was pacing around the room so I went in and talked with him. He said he wanted to go home. I asked him if he wanted anything to calm his nerves. He said no." ED RN M stated, "He was looking out the door every time I interacted with him. He seemed a little down and wanted to go home." When asked if the ED physician was aware of Patient #1's behaviors, ED RN M stated, "[ED Physician QQ] was aware the patient was pacing most of the night but it was a verbal exchange of information and most likely it would not be documented in the medical record."